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Emergency Medicine > Pulmonary Emergencies > Flashcards

Pulmonary Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Causes of Upper Airway Obstruction

A

Foreign body
Tongue
Swelling/edema

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2
Q

Upper Airway Obstruction Etiology

A 
Foreign body
Retropharyngeal abscess
Angioedema
Head and neck trauma
Swelling/edema from inhalation injuries
Epiglottitis
Croup
Tonsillitis
Peritonsillar abscess
Ludwig's angina
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3
Q

Types of Foreign Body Obstruction

A

Incomplete

Complete

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4
Q

Where does the retropharyngeal space extend from and go to?

A

Base of the skull to the tracheal bifurcation

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5
Q

Etiology of Retropharyngeal Abscess in Children

A

Lymph node that drains the head and neck

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6
Q

Etiology of Retropharyngeal Abscess in Adults

A

Penetrating trauma
Infection in the mouth/teeth
Lymph nodes that drain the head and neck

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7
Q

Signs and Symptoms of a Retropharyngeal Abscess

A 
Fever
Dysphagia
Neck pain
Limitation of cervical motion
Cervical lymphadenopathy
Sore throat
Poor oral intake
Muffled voice
Respiratory distress
Stridor (children)
Inflammatory torticollis
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8
Q

Work Up of Retropharyngeal Abscess

A

Lateral soft tissue X-ray of the neck during inspiration

CT scan of the neck: “gold standard”

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9
Q

Treatment of Retropharyngeal Abscesses

A

Immediate ENT consult
Surgical I&D
IV hydration
IV antibiotics

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10
Q

Antibiotics for a Retropharyngeal Abscess

A

Clindamycin

Ampicillin-sulbactam (Unasyn)

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11
Q

Complications of a Retropharyngeal Abscess

A

Extension of infection into mediastinum
Pleural or pericardial effusion
Upper airway asphyxia
Sudden Rupture: aspiration pneumonia or widespread infection

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12
Q

Define Angioedema

A

Subdermal or submucosal swelling

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13
Q

Describe the Swelling in Angioedema

A

Diffuse

Non-pitting

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14
Q

Assessment of Angioedema

A

Rapid assessment of airway

Close monitoring

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15
Q

What areas of the body does angioedema generally affect?

A 
Face
Lips
Mouth
Throat
Larynx
Extremities
Genitalia
Bowel
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16
Q

Etiology of Angioedema

A

Mast cell mediated

Bradykinin mediated

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17
Q

What medications does mast cell mediated angioedema respond to?

A

Epinephrine
Glucocorticoids
Antihistamines

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18
Q

What conditions or medications does bradykinin mediated angioedema occur secondary to?

A

ACE-inhibitors

Hereditary angioedema

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19
Q

Treatment of Allergic Angioedema

A

Intubation if signs of respiratory distress
Epinephrine (0.3 mg IM)
Glucocorticoids
Diphenhydramine (25-50 mg IV)

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20
Q

Treatment of ACE Inhibitor Induced Angioedema

A

Intubation if signs of respiratory distress
Discontinue offending drug
If severe or no improvement in 24 hours: antihistamines, glucocorticoids, C1 inhibitor therapy

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21
Q

Treatment of Hereditary Angioedema

A

Intubation if signs of respiratory distress
C1 inhibitor if available
Bradykinin receptor antagonist

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22
Q

Define Anaphylaxis

A

Acute, potentially lethal, multi system syndrome from the sudden release of mast cells and basophils into the circulation

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23
Q

Presentation of Anaphylaxis

A 
Sudden onset urticaria
Angioedema
Flushing
Pruritus
Hypotension
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24
Q

Treatment of Anaphylaxis

A

Epinephrine

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25
Q

Airway Management in Anaphylaxis

A

Immediate assessment for wheezing, stridor, and difficulty breathing
Intubation if marked stridor or respiratory arrest

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26
Q

Treatment of Anaphylaxis

A 
Assess airway
IM epinephrine
O2 via nonrebreather (patent airway)
2 large bore IVs
NS rapid bolus via IV (1-2L)
Consider: albuterol nebulizer, H1 blocker, H2 blocker, methylprednisolone
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27
Q

Usually Medications Given in Anaphylaxis

A 
Epinephrine
H1 blocker: diphenhydramine
H2 blocker: ranitidine
Glucocorticoid: solu-medrol
Albuterol nebulizer
Possible vasopressors
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28
Q

Possible Assessment Findings in Head and Neck Trauma

A

Gurgling
Snoring
Stridor
Wheezing

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29
Q

Define Gurgling

A

Pooling of liquids in the oral cavity or hypopharynx

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30
Q

Define Snoring

A

Partial airway obstruction at the pharyngeal level from the tongue

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31
Q

Define Stridor

A

Inspiratory: obstruction at the level of the larynx
Expiratory: obstruction at the level of the trachea

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32
Q

Define Wheezing

A

Narrowing of lower airways

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33
Q

Important Aspect in Head and Neck Trauma

A

Securing the airway

Avoid nasotracheal intubation

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34
Q

Stupor/Coma and Airway

A

Inability to protect airway due to lack of gag reflex

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35
Q

Define Stupor

A

Lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only response to base stimuli such as pain

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36
Q

Define Coma

A

State of unconsciousness lasting more than 6 hours in which a person cannot be awakened; fails to respond normally to painful stimuli, light or sound; lacks a normal sleep-wake cycle; and does not initiate voluntary actions

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37
Q

Define Pneumothorax

A

Accumulation of air in the pleural space

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38
Q

Describe a Spontaneous Pneumothorax

A

Pneumothorax that occurs without a precipitating event in a person without lung disease

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39
Q

Risk Factors for a Spontaneous Pneumothorax

A 
Men
Age: 20-40
Thin build
Smokers
Family history
Marfan syndrome
Prior episode
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40
Q

Presentation of a Spontaneous Pneumothorax

A

Sudden onset of dyspnea and pleuritic chest pain

Often occurs at rest

41
Q

Physical Exam Findings in Pneumothorax

A 
Decreased chest excursion
Decreased breath sounds on the affected side
Hyperresonant to percussion
Possible subQ emphysema
Hypoxemia
Suspicion of tension pneumothorax
42
Q

When should one suspect a tension pneumothorax?

A 
Labored breathing
Tachycardia
Hypotension
Tracheal shift
JVD
43
Q

Treatment of Pneumothorax

A

Supplemental O2
Needle decompression
Chest tube placement

44
Q

Presentation of Acute Pulmonary Edema

A 
Dyspnea
Frothy pink sputum
Pedal edema
Ascites
Rales
Wheezing
HTN
Hypoxemia
Restlessness
Tachycardia
Look ill
Cold sweat
45
Q

Types of Acute Pulmonary Edema

A

Cardiogenic

Non-cardiogenic

46
Q

Acute Causes of Cardiogenic Pulmonary Edema

A 
Ischemia
Acute severe mitral regurgitation
Acute aortic regurgitation
Hypertensive crisis secondary to bilateral renal artery stenosis
Stress induced cardiomyopathy
47
Q

Chronic Causes of Cardiogenic Pulmonary Edema

A

Decompensated systolic CHF
Decompensated diastolic CHF
Left ventricular outflow tract (LVOT) obstruction
Valvular heart disease

48
Q

Noncardiogenic Pulmonary Edema

A 
ARDS
Altitude
Neurogenic
Narcotic overdose
Pulmonary embolism
Eclampsia
Transfusion related injury
Salicylate overdose
49
Q

Etiology of ARDS

A 
Sepsis
Acute pulmonary infection
Trauma
Inhaled toxins
DIC
Shock lung
Freebase cocaine smoking
Post CABG
Inhalation of high concentrations of O2
Acute radiation pneumonitis
50
Q

Treatment of Cardiogenic Acute Pulmonary Edema

A 
O2
Treat underlying cause
Ischemia
Valvular disease
Treat arrhythmias
51
Q

Treatment of Noncardiogenic Acute Pulmonary Edema

A

O2
Treat underlying cause
Likely intubation and mechanical ventilation with PEEP
Diuretics

52
Q

Treatment of Generalized Acute Pulmonary Edema

A

Assess the airway and stability of the patient
Furosemide (Lasix) if hemodynamically stable
Supplemental O2
Treat underlying cause

53
Q

Pathophysiology of Asthma

A

Inflammation of the airways with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts
Reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema, and thick secretions

54
Q

Things to Beware of During Assessment of Acute Asthma

A 
Use of accessory muscles of respiration
Fragmented speech
Orthopnea
Diaphoresis
Agitation
Low blood pressure
Severe symptoms that fail to improve
55
Q

Findings Demonstrating Impending Respiratory Failure in Acute Asthma

A

Inability to maintain respiratory effort and rate
Cyanosis
Depressed mental status
Severe hypoxemia despite high flow O2 via non-rebreather

56
Q

Assessment of Acute Asthma

A 
Measure peak flow
Supplemental O2
Establish IV access
Frequent reassessment
ABGs & CXR not useful initially
57
Q

How does peak flow help in the assessment of an acute asthma patient?

A

Provides an objective measurement as to the severity of airflow obstruction

58
Q

When should you measure peak flow?

A

Before and after each nebulizer or MDI treatment

59
Q

Medical Therapy for Acute Asthma

A 
Albuterol
Ipratropium bromide
Methylprednisolone
Magnesium sulfate
Epinephrine
Terbutaline
60
Q

Function of Albuterol

A

Bronchodilator

61
Q

Function of Ipratropium Bromide

A

Bronchodilator

With the albuterol = Duoneb

62
Q

Function of Methylprednisolone (Solu Medrol)

A

Decreases airway inflammation

63
Q

When is magnesium sulfate given in an acute asthma patient?

A

Life threatening exacerbations that remains ever after 1 hour of intense bronchodilator therapy

64
Q

When is epinephrine given in an acute asthma patient?

A

Suspected anaphylactic reaction or unable to use inhaled bronchodilators

65
Q

When is terbutaline given in an acute asthma patient?

A

Severe asthma unresponsive to standard therapy

66
Q

What is a COPD exacerbation generally precipitated by?

A

Viral or bacterial infection

67
Q

Define COPD Exacerbation

A

Increase or change in character of usual symptoms of dyspnea, cough, or sputum production

68
Q

Work Up of a COPD Exacerbation

A 
O2 saturation
ABG: severe
CXR
CBC (+/-)
BMP (+/-)
BNP (+/-)
EKG
69
Q

What is a CXR assessing for in COPD exacerbations?

A

Pneumonia
Acute heart failure
Pneumothorax

70
Q

Pharmacotherapy for COPD Exacerbation

A

Supplemental O2
Solumedrol (methylprednisolone)
Antibiotics: cover pseudomonas
Inhaled bronchodilators

71
Q

When would you consider hospital admission for a COPD exacerbation?

A

Symptoms severe enough to prevent ADLs and IADLs
Failure to respond to initial therapy
High risk co-morbidities
Worsening hypoxemia

72
Q

What are high risk co-morbidities in a COPD exacerbation?

A 
Pneumonia
CHF
Arrhythmia
Liver failure
Kidney failure
DM
73
Q

What is the treatment of impending respiratory failure in a COPD exacerbation?

A

Intubation

Non-invasive positive pressure ventilation

74
Q

Define Pulmonary Embolism

A

Obstruction of the pulmonary artery or branches with clot, tumor, air, or fat

75
Q

Signs and Symptoms of Pulmonary Embolism

A 
Dyspnea
Tachypnea
Cough
Hemoptysis
Syncope
Lower extremity edema
Cyanosis
Diaphoresis
Hypotension
Rales (+/-)
Lower extremity pain or erythema
76
Q

Risk Factors for Establishing a Pulmonary Embolism

A 
Pregnancy
Obesity
Prolonged immobilization
Hormones: BCPs, HRT, SERMs
Cancer
Trauma
Recent joint replacement surgery
History of DVT
Autoimmune disease
HTN
Smoking
CHF
77
Q

Wells Criteria for Pulmonary Embolism

A

Clinical Signs and Symptoms of DVT
PE Is #1 Diagnosis, or Equally Likely
Heart Rate > 100
Immobilization at least 3 days, or surgery in the Previous 4 weeks
Previous, objectively diagnosed PE or DVT
Hemoptysis
Malignancy w/ treatment within 6 mo, or palliative

78
Q

Work Up of Pulmonary Embolism

A 
CTA of the chest with PE protocol
CXR
EKG: sinus tach
Echo +/-
V/Q scan
D-dimer
Doppler US of LE
79
Q

What changes can you see on lead I of an EKG for a pulmonary embolus?

A

S-waves

80
Q

What changes can you see on lead III of an EKG for a pulmonary embolus?

A

Q-waves

Inverted T-waves

81
Q

Treatment and Stabilization of an Acute PE

A

Supplemental O2

Hypotensive: fluid bolus, vasopressors

82
Q

What vasopressors are used to treat an acute PE?

A

Norepinephrine
Dopamine
Epinephrine
Dobutamine + norepinephrine

83
Q

Pharmacologic Treatment of Acute PE

A

Unfractionated heparin (UFH)
Low molecular weight heparin (LMWH)
Fondaparinux

84
Q

Treatment of Acute PE

A

Vitamin K agonist should be started same day as anticoagulant therapy
Continue Lovenox until INR is 2.0
Thrombolytics??

85
Q

Signs and Symptoms of Pneumonia

A 
Cough
Fever
Chills
Pleuritic chest pain
Dyspnea
Sputum production
Mental status changes
GI symptoms (N/V/D)
Tachypnea
Tachycardia
Hypoxia
Rales, rhonchi, or decreased in area of consolidation
86
Q

Work Up of Pneumonia

A 
PA and lateral CXR
CBC, CMP
Blood cultures
Sputum for gram stain and culture
Pneumococcal and Legionella urine antibody tests
87
Q

Hospital Admission Pneumonic’s for Pneumonia

A

PSI

CURB-65

88
Q

Components of a PSI Score

A 
Age
Gender
Nursing home resident
Neoplastic disease
Liver disease history
CHF history
Cerebrovascular disease history
Renal disease history
Altered mental status
RR 29+
SBP less than 90 mmHg
Temp: less than 35 or 39.9+
Pulse: 124+
pH: less than 7.35
BUN: 29+
Sodium: less than 130
Glucose: 249+
Hematocrit: less than 30%
pO2: less than 60 mmHg
Pleural effusion
89
Q

Components of CURB-65

A 
C: confusion
U: urea (BUN >19 mg/dL)
R: RR >30
B: SBP less than 90 or DBP less than 60
65: 65+ years old
90
Q

Treatment of Pneumonia

A 
Supplemental O2
Intubation or NiPPV if respiratory failure
Antibiotics
Fluids
Antipyretics
Albuterol nebulizer (+/-)
Incentive spirometry
91
Q

Most Likely Pneumonia Pathogen

A

Strep pneumo

92
Q

Non-ICU Hospital Admission Pneumonia Pathogens

A 
Strep pneumo
Respiratory viruses
M. pneumoniae
H. flu
C. pneumoniae
Legionella
93
Q

Antibiotics for Non-ICU Pneumonia Patients

A

Respiratory fluroquinolone OR antipneumococcal beta-lactam
PLUS
Macrolide

94
Q

Examples of Respiratory Fluroquinolones

A

Levofloxacin
Moxifloxacin
Gemifloxacin

95
Q

Examples of Antipneumococcal Beta-Lactam

A

Cefotaxime
Ceftriaxone
Ampicllin-sulbactam (Unasyn)

96
Q

Examples of Macrolides

A

Azithromycin
Clarithromycin
Erythromycin

97
Q

Pathogens for Patients Requiring ICU Admission for Pneumonia

A 
S. pneumoniae
Legionella
Gram-negative bacilli
Staph aureus
Consider MRSA
98
Q

Antibiotics for ICU Pneumonia

A

Antipneumococcal beta-lactam + azithromycin
Antipneumococcal beta-lactam + respiratory fluoroquinolone
Penicillin allergy: respiratory fluoroquinolone + aztreonam

Emergency Medicine (17 decks)

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